Comparison of Breast Pocket Irrigation Solutions in Regards to Capsular Contracture and Infection Rates: Retrospective Review of 388 Primary Breast Augmentation Patients
Capsular contracture remains a significant problem for both breast augmentation and breast reconstruction patients, with rates quoted in literature between 1.7 to 28.7%. Despite near universal agreement amongst plastic surgeons that breast pocket irrigation significantly reduces the risk of periprosthetic infection and capsular contracture, the type of irrigation solution used remains highly variable. Triple antibiotic solution with or without betadine was previously the most commonly used irrigation solution amongst plastic surgeons (Epps et al, 2019), prior to the FDA recall of bacitracin in 2019. Several studies have demonstrated that stable 0.025% hypochlorous acid is effective in bacteria and biofilm eradication without cytotoxicity or allergic reactions. Our retrospective study aimed to compare several breast pocket irrigation solutions used in a single practice group, in regards to their post-operative outcomes.
Methods/Technique:
A retrospective chart review was performed utilizing data from four board-certified aesthetic plastic surgeons in a single plastic surgery group. The study examined 388 primary breast augmentation patients (776 breasts) who had their surgeries done between 2018 and 2019. All breast augmentations were performed following Tebbet’s 14 point plan. All augmentations were done with smooth implants in a dual plane, using nipple shields and a funnel.
Varying solutions / combinations were used for breast pocket irrigation with the most numerous categories being: triple antibiotic with betadine, double antibiotic with betadine, triple antibiotic alone, double antibiotic alone, 0.025% hypochlorous acid, 0.05% chlorhexidine gluconate.
Patients were excluded if they had 1 follow up appointment or less, had <3 weeks of follow-up or had a history of previous breast augmentation.
Outcomes that were evaluated included capsular contracture (Baker grades I - IV), mild infection (resolved with PO antibiotics) and severe infection (requiring explanation).
Results/Complications:
A total of 388 primary breast augmentation patients (776 breasts) were identified and included in the study, with 211 patients from 2018 and 177 patients from 2019. Average follow time was 9 months. In order of most commonly used to least commonly used irrigation solution, the capsular contracture rates were as follows: triple antibiotic solution (TAS) + betadine 4/346 (1.16%), 0.025% hypochlorous acid (HOCl) 0/162 (0%), TAS 1/110 (0.91%), 0.05% chlorhexidine gluconate (CHG) 0/82 (0%), double antibiotic solution (DAS) + betadine 3/42 (7.14%), CHG + betadine 0/34 (0%), DAS 1/24 (4.17%), CHG + TAS + betadine 0/10 (0%), single antibiotic solution (SAS)+ betadine 0/10 (0%), CHG + TAS 0/6 (0%), SAS 0/2 (0%).
In total, there were 7 patients who presented with capsular contracture, involving a total of 8 breasts. Of note, none of the patients who had CHG or HOCl irrigation had capsular contracture.
There were a total of 8 periprosthetic breast infections out of 776 augmented breasts total. Five infections out of the 8 were mild infections that resolved with PO antibiotics alone and 3 were severe that required explantation. TAS + Betadine group had 3 mild, 1 severe infections; hypochlorous acid group had 1 mild, 1 severe infections; CHG group had 1 severe infection; lastly TAS alone had 1 mild infection. No patients had both capsular contracture and infection. Of note, the patient that had a severe infection in the hypochlorous acid group was a patient with Crohn's disease and was on remicade.
Conclusion:
Overall, there was a 1.03% capsular contracture rate (8/776) in 7 out of 388 patients (1.8%). The cases occurred in those irrigated with TAS, TAS + Betadine, DAS + Betadine, and DAS. None of the patients irrigated with 0.05% CHG or 0.025% hypochlorous acid had postoperative capsular contracture. Overall infection rate was 8 out of 388 patients (2.06 %) or 8 out of 776 breasts (1.03%) including five mild and three severe infections.
Our study demonstrated that there were higher rates of capsular contracture seen with solutions containing double or triple antibiotic than with 0.05% chlorhexidine or 0.025% hypochlorous acid based solutions. Infection rates were similar across the irrigation solution groups.